Living in a Body Shaped by Violence: What Practitioners Need to Know About Identifying Child Abuse
By Ruth Reymundo Mandel, Chief Business Development Officer and Credible Expert, Safe & Together Institute
When we think about childhood abuse, too often the image that comes to mind is a visible bruise, a broken bone, or a single violent incident. But for many children, the impact of abuse is etched far deeper—into their tendons, joints, nervous system, and even their immune response. These injuries may not always be visible, but the violence and the impact shape the child’s daily reality and long-term health in profound ways.
This article brings together two perspectives: the medical evidence of chronic injury and the lived reality of a child growing up with those injuries inside an institutional setting. I used my MRI findings to speak about the symptoms I experienced from severe and ongoing violence in an institutional setting. This is to help practitioners learn how to better identify and work with children who are being chronically abused but do not fit the injury focus of “radial fractures and bruises,” which dominates the thinking of mandatory reporters and dangerously renders those children and the abuse they are enduring invisible.
From Perpetrator Actions to Lifelong Injuries
Consider a child subjected to repetitive yanking of arms, repetitive shaking, and sexual assault with restraint. These aren’t isolated acts—they’re a pattern of abuse that leaves measurable traces in the body:
Shoulders/Arms: Chronic tendon strain and joint degeneration from repeated pulling
Neck/Spine: Disc protrusions and narrowing from shaking, resulting in searing pain when turning the head
Pelvic/Anal Assault: Tendon damage, pelvic fluid, and chronic pelvic and hip pain from sexual assault with restraint
Whole Body: Lingering stomach aches and autoimmune disease linked to toxic stress and the inflammation of many traumatic injuries
These aren’t “growing pains” or psychosomatic symptoms. They’re markers of sustained, severe abuse.
The Child’s Daily Reality
For a child living with sustained and severe abuse and the concurrent injuries, every day is shaped by pain, protection, and coping strategies:
Sitting in a hard school chair means knives of pain in hips and pelvis. Teachers may see restlessness or refusal to sit still, but the reality is physical agony. And when teachers respond with demeaning or further violence, it compounds that reality and adds to the injuries.
Turning to look at a board in class can send fire down the neck from spinal injury. Staff might label the child as disengaged or oppositional.
Frequent stomach aches and bathroom trips aren’t malingering; they are trauma’s legacy in the digestive system.
Daydreaming or zoning out isn’t inattention; it’s dissociation, a survival strategy against pain and overwhelming fear.
These aren’t “bad behaviors.” They are the visible face of hidden injuries. And understanding what they tell us about what a child may be experiencing can assist us in asking relevant questions about their experience.
Questions Practitioners Can Ask
“What happens when you tell someone you’re hurt? How do the adults around you respond?”
“Are there times when someone stops you from going to the nurse or asking for help?”
“What do the adults say when you cry or show pain?”
“Who decides when you can rest, sit down, or get a break when you’re hurting?”
“Has anyone ever made fun of you, punished you, or told you to stay quiet when you were in pain?”
“What happens if you say you don’t want to do something because it hurts?”
“Does anyone tell you not to talk about fear, injuries, or stomach aches?”
These questions focus less on the child’s internal coping and more on how adults and caregivers around the child may be responding, controlling, or dismissing their pain. They help uncover perpetrator patterns of behavior and how systems may be reinforcing silence or invisibility of abuse.
Practitioner Reflection Questions
“Am I recording this child’s pain as an isolated symptom or connecting it to the caregiver’s pattern of behaviors?”
“Have I asked how the perpetrating adult may be interfering with medical care, school attendance, or rest?”
“Do I notice when adults dismiss or punish a child’s pain, and am I documenting that as part of the perpetrator’s controlling pattern?”
“When mapping, am I focusing on how the perpetrator’s choices are creating multiple pathways to harm rather than framing the child or protective parent as the problem?”
“How can I use the mapping tool to clearly show the link between the perpetrator’s tactics (e.g., restraint, silencing, denial of care) and the child’s lived symptoms (e.g., pain, zoning out, stomach aches, headaches, chronic fatigue)?”
These reflection questions help practitioners align daily observations with the Safe & Together Perpetrator Pattern Mapping Tool, ensuring they are not just describing child behaviors but documenting how those behaviors connect back to adult choices and patterns of control. They help practitioners give children the opportunity to describe their lived reality without fear of being dismissed or punished. They focus on the child’s perspective and body-based experiences, instead of assuming defiance or illness.
Institutional Misinterpretations
In care settings, children with complex trauma often encounter another layer of harm: Their symptoms are misunderstood or punished.
Restlessness is treated as rule-breaking, instead of a child trying to relieve pain.
Repeated nurse visits are dismissed as attention-seeking, instead of recognised as attempts to cope with real injuries.
Dissociation in class is seen as laziness, instead of a child’s mind protecting itself.
The risk is that staff respond with further harm, removal of rights, and physical discipline instead of support, compounding harm and trauma instead of helping to heal it.
Reframing for Care Workers
To truly meet the needs of these children, care workers must shift their lens:
Validate Pain: Believe children when they say it hurts. Ask the next question.
Adapt Environments: Provide flexible seating, cushions, movement breaks, and private bathroom access.
Reframe Behavior: Restlessness is pain management. Zoning out is dissociation. Withdrawal is self-protection and an attempt to heal.
Build Trust: Respect boundaries and provide safe, non-invasive care.
Use Medical Evidence: Recognize that MRI findings and chronic illnesses are proof of trauma’s impact, not coincidence.
The Safe & Together Framework
Using the Safe & Together Model, we can see this child’s experience through the right lens:
Perpetrator Accountability: These injuries and illnesses are the direct results of abusive choices, not the child’s or protective parent’s failures.
Multiple Pathways to Harm: The abuse didn’t just cause immediate injuries. It disrupted education, daily functioning, emotional well-being, and negatively impacted lifelong health.
Partnering with Survivors: Whether the child is in family or institutional care, their coping strategies deserve to be recognized as strengths, not pathologized as problems.
The Call to Action
For care workers, educators, and practitioners, the challenge is clear: Stop misinterpreting the survival strategies of abused children. A child who can’t sit still, who daydreams, who complains of pain, headaches, and stomach aches isn’t being difficult—they’re telling us their story in the only ways their body and mind know how.
Our role is to listen differently. To ask the right questions and to always hold the perpetrator accountable for the patterns of harm that ripple through a child’s body and life.
Because beyond the bruises are the hidden injuries and a potentially ongoing pattern of harm. And beyond the injuries are children who deserve to be believed, understood, safe, and supported to heal.
Additional Resources
Blog: Beyond Broken Bones: Why We Must See Soft Tissue Injury as a Red Flag for Child Abuse
Safe & Together Institute’s domestic abuse–informed trainings
Safe & Together Institute’s upcoming events
David Mandel’s book Stop Blaming Mothers and Ignoring Fathers: How to Transform the Way We Keep Children Safe from Domestic Violence
